Please Note: If there are any errors between this document and the contract, the contract covering the benefits will prevail for accuracy.

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1 Please Note: If there are any errors between this document and the contract, the contract covering the benefits will prevail for accuracy. HEALTH CARE BENEFITS Hospital s (100% reimbursement) Semi-private Charges for semi-private room accommodation in a hospital accommodation Specialized Care Facility Charges for accommodations in a specialized care facility Ambulance Services Charges for licensed professional ground ambulance transportation Extended Health s (100% reimbursement) Private Duty Nursing Charges for home nursing care performed by a private duty nurse (not a relative of the patient or an employee of the hospital) when ordered by an attending physician. Services provided by an approved personal care worker are eligible for up to four hours a day Only those services pre-approved by Medavie Blue Cross will be considered The maximum eligible expense for each participant is limited to 5,000 in any 12 consecutive months. Medical Equipment Charges for the rental of : o wheelchair, scooter o standard hospital bed o walkers, canes o medication compressor o insulin pumps (including infusion pumps) o compression pumps or o other DURABLE medical equipment required for therapeutic use Charges must be pre-approved by Medavie Blue Cross Diagnostic X-Ray Medical Supplies & Services Medical Prosthesis Diagnostic and X-ray services, when carried out by a Medavie Blue Cross approved laboratory. Charges for blood, blood plasma when not supplied as a free service and charges for Radium isotope therapy when rendered in an approved Medavie Blue Cross provider facility Charges for the purchase, repair, adjustment or maintenance of prosthetic limbs and eyes. Replacements only in the event of pathological change. Charges for one breast prosthesis in a 24-month period. Two breast prostheses in the event of a bilateral mastectomy in a 24-month consecutive period. Cost of two surgical brassieres in any 12-month consecutive period. Hair, when hair loss is due to an underlying pathology or its treatment, not to exceed $200 in any period of 12 consecutive months. Artificial Larynx, to a frequency of one occurrence in a lifetime. Larynx repair and adjustment is limited to a maximum Eligible Expense of $300 in a calendar year. Medical Supplies Ostomy appliances, irrigating sets, and pouches. Charges for urinary collection and retention systems including catheter tubes and pouches. Charges for diabetic insulin pump supplies including needles, syringes and testing materials. Special garments for treatment of burns. Enuresis detection devices, limited to one in any 60 consecutive month period. Intra-uterine contraceptive devices, limited to one in any 12 consecutive month period. Charges for other medical supplies approved by Medavie Blue Cross

2 Charges for elastic support stockings, limited to two pairs per participant in any 12 consecutive month period. Oxygen and Oxygen Charges for the purchase of oxygen and rental of equipment required for its Supplies administration, on the order of the attending physician. Equipment may be purchased at the option of Medavie Blue Cross. Supports Cervical collars. Splints. Trusses. Traction devices. Custom fitted braces of rigid construction. Charges must be pre-approved by Medavie Blue Cross Orthotics (molded arch Charges for custom molded foot supports as prescribed by an orthopedic surgeon, supports) physiatrist, rheumatologist or the attending physician up to $200 per participant in a calendar year or $300 in a calendar year if participant is under 21 years of age. Orthotics must be fitted by and purchased from an orthopedic foot care provider approved by Medavie Blue Cross. The Orthotic does not include charges for off the shelf Orthopedic Shoes and Customized orthopedic shoes to accommodate, relieve, or remedy some mechanical foot Modifications defect or abnormality and charges for shoe modification and adjustment supplies. Must be prescribed by an orthopedic surgeon, physiatrist, rheumatologist or the attending physician. The maximum in any 12 consecutive month period is $100. Emergency Transportation Charges for emergency transportation by air, rail or water to the nearest medical facility able to provide the required care is covered when: an area is not serviced by licensed ground ambulance; or the urgency of the situation requires that only such form of transportation is adequate. Limit of $500 per participant for any one emergency illness or accident. Coverage includes the cost of return transportation for a registered nurse when it is medically necessary. Dental Services Accidental The services of a dentist or dentist specialist for the repair or replacement of natural teeth Injury that have been damaged by a direct, accidental blow to the mouth, or fractured or dislocated jaw requiring setting. An accident report must be submitted before claims will be considered for payment. Services must be completed within 12 months of the date of accident provided the participant s coverage remains in force. When a planned course of treatment is expected to be more than $300 (other than on an immediate emergency basis), Medavie Blue Cross must receive an estimate of the proposed treatment and charges, and dental X-rays where applicable. Private Practice Charges for treatment, except when performed in a hospital, by a licensed speech Para-medical Services therapist, massage therapist, chiropractor, chiropodist/podiatrist, occupational therapist, physiotherapist (physician confirmation required) or acupuncturist to a maximum eligible expense of $500 for each type of practitioner in any calendar year. The overall maximum eligible expense is $1,500 in one calendar year. In addition, the maximum eligible expense for X-rays in one calendar year is $35 per practitioner. Psychologist/Social Worker Combined maximum eligible expense is $800 in a calendar year for a licensed psychologist or social worker. The social worker must be a Master Social Worker (MSW), licensed and registered to be eligible. Naturopath, Osteopath, Charges for a licensed naturopath, osteopath or homeopath to a maximum eligible Homeopath expense of $300 per practitioner in a calendar year. Hearing and Speech Aids Hearing aids up to $750 in any period of five consecutive years when prescribed by an otolaryngologist or clinical audiologist following referral by a physician. Auditory Training System when required by a Child for language development or for classroom use to a maximum of $1,000 in a lifetime of a participant. Speech Aid Equipment for participants who do not have oral communication ability to a lifetime maximum of $500.

3 Vision Care s (100% reimbursement) Vision Services must be performed by a licensed optometrist or ophthalmologist. Services are covered every two consecutive calendar years; every calendar year for dependent children under 18 years of age. Optometrist or ophthalmologist services for one eye refraction up to the usual, reasonable and customary charges as determined by Medavie Blue Cross. The purchase of frames and prescription lenses or prescription contact lenses up to $150. Special Contact Lens - Charges for contact lenses and professional fitting services up to $200 per benefit period for non-elective, medically-necessary conditions. Prescription Drugs Prescription Drug Coverage Dispensing Fee co-payment with annual maxim of $492. No coverage of over-the counter drugs, except items considered life sustaining and approved by Medavie Blue Cross. Smoking cessation products are included for one course of treatment up to a lifetime maximum of 3 consecutive months\ Dental Care s Frequency of Dental Recall Exams Fluoride Treatment Basic Dental and Major Restorative Services Orthodontic Dental Services Frequency of dental recall exams (and related services such as X-rays, scaling and polishing) is limited to once per calendar year for participants age 18 and over, twice per calendar year for participants under age 18. Fluoride treatments are limited to two procedures every calendar year for each participant under age 18. Level 1 Services covered at 100% of the eligible expense, and subject to specific internal plan maximums. Maximum Payable for Level 1 includes the following: Diagnostic, Preventive, Oral Surgery, Minor Restorative, and Adjunctive Services are $1,000 per participant per calendar year. Level 2 and 3 Services covered at 80% of the eligible expense, and subject to specific internal plan maximums. Combined Maximum Payable for Level 2 and 3 includes the following: Prosthetic/Restoration Maintenance, Endodontics, Periodontics, Major Restorative, Prosthodontics is $1,000 per participant per calendar year. Level 4 services covered at 50% of the eligible expense, and subject to specific internal plan maximums. Maximum : Lifetime maximum orthodontic benefit per participant is $2,000. Orthodontic observations and adjustments. An orthodontic treatment plan must be submitted and confirmation of the payment schedule will be provided at that time. World Wide Travel (100% reimbursement*)

4 Hospital Accommodation Physicians and Surgeons Wheelchairs, Crutches, Canes Nurse Ambulance Coming Home Diagnostic Services Paramedical Services Drug Dental Services The cost of a public general hospital, less the amount allowed under the provincial government health plan, for (a) room accommodation (not a suite) and (b) medically necessary inpatient and outpatient services. Customary charges by physicians and surgeons for services rendered, less the amount allowed under the provincial government health plan. The cost of temporary rental of a wheelchair, crutches and/or canes, when required due to an accident or sudden illness which occurs outside the province of residence and when ordered by a physician. Charges for private duty nursing (not a relative of the patient or an employee of the hospital) when ordered by an attending physician. Normal charges for ambulance service, including air ambulance and evacuation to and from the nearest qualified medical facility. Extra costs of return economy fare by the most direct route (air, bus, train) when an illness is such that the patient must return home and be accompanied by a qualified medical attendant (not a relative). Written authorization is required from the attending physician. If returning on a commercial aircraft, this coverage is included: two economy seats by most direct route to the patient s home city in Canada, one for the covered patient and one round trip fare for the medical attendant; the number of economy seats required to accommodate the covered person if on a stretcher and one round trip for a medical attendant. Charges for laboratory services for diagnostics and X-rays when ordered by the attending physician. Charges made by a licensed chiropractor, osteopath, chiropodist/podiatrist or physiotherapist (not a relative), in excess of payment by the provincial government health plan. Charges for drug benefits in a quantity sufficient for the period of travel. Payment of eligible drugs will be made only when proof of purchase is supplied in the form of an account from a Medavie Blue Cross approved provider located outside the covered person s province of residence and showing the name of the preparation, date of purchase, quantity, strength and total cost. Charges for dental treatment to a maximum of $1,000 Canadian when, as the result of accidental injury (direct accidental blow to the mouth), natural teeth have been damaged, or fractured or dislocated jaw requires setting. Such dental treatment must be rendered or reported and approved for payment by Medavie Blue Cross within 180 days of the accident and be supported by proper certificate. Vehicle Return When such dental treatment must be deferred because of the age of the patient, or other factors, which are justified in the opinion of Medavie Blue Cross, the claim may be approved for later payment. To meet the payment criteria, the participant must have been covered by Medavie Blue Cross for Accidental Dental at the time the accident occurred, and must still be covered by Medavie Blue Cross at the time the services are rendered. The only exception to this criteria is when the participant is uninsured for Dental benefits at the time the service is rendered, in which case the claim may be approved. The subscriber must submit to Medavie Blue Cross within 180 days of the accident complete details of the required services from the Dentist and reason for deferment. An allowance of up to $500 Canadian for the cost of driving the patient s vehicle, whether private or rental, by commercial agency to the patient s residence or nearest appropriate vehicle rental agency when the patient is unable to return it due to sickness or accident. Return of Deceased Maximum: $3,000. Charges for the cost of preparation and homeward transportation of the deceased covered person (excluding the cost of a coffin) to the point of departure in Canada by the most direct route. Meals and Accommodation Maximum: $700 ($100 per day for seven days) per trip. Charges for extra costs of commercial accommodation and meals incurred by a covered person, remaining with a travelling companion when the trip is delayed due to illness or accident to a travelling companion or a covered person. This must be verified by the attending physician and supported with receipts from commercial organizations.

5 Transportation to visit the Covered Person Emergency and Payment Assistance Charges for one return economy fare by the most direct route for transportation costs (air, bus, train) when the covered person has been confined to the hospital for 7 days or has died, and the attending physician has advised of the necessity of the attendance of a family member or close friend of the covered person. The services of a 24-hour emergency hotline are available to covered persons who need assistance while travelling. By telephoning the appropriate number on your Medavie Blue Cross identification card when a medical emergency occurs, coverage will be confirmed to the hospital or physician. Payment of medical expenses will be arranged or coordinated on behalf of the covered person. In addition, the following services are offered: Medical Assistance - the covered person may call for a list of hospitals or medical facilities and arrangements will be made for: advice from a qualified physician, medical follow-up of the covered person s condition and communication with the employee and family, return home or transfer of covered person if medically permissible, transport of a family member to the covered person s bedside or to identify the deceased. Non Medical Assistance - the covered person may call to obtain: an emergency response in any major language, emergency assistance in contacting the family or business, referral to legal counsel.